BFMS Intramural Form - Parent Permission
Any participant in athletics must have this form completed and returned to the Athletic Director before participation will be allowed.
Email address *
Student Name *
First and last name
School Year *
Date of Birth *
Phone number where a parent can be reached: *
My child has permission to play (please check all that apply:) *
Insurance Company *
Policy Number *
Emergency Contact #1: (Name & Phone Number) *
Emergency Contact #2: (Name & Phone Number)
Emergency Contact #3: (Name & Phone Number)
Please list any health concerns/issues your child may have: *
Allergies: *
Medications: *
By giving my permission, I will accept responsibility for helping administer the Bellows Falls Middle School Athletic Policy, and release my son/daughter to be treated by medical personnel and transported to a medical facility in the event of injury. *
By signing this form we state that we were provided the Center for Disease Control Fact Sheet regarding concussions in youth sports by the Bellows Falls Middle School. (Link: *
By signing this permission form, we acknowledge that we have read the information and the information contained in the Student Intramurals Handbook. (Link: *
We further acknowledge that we have the appropriate medical insurance coverage. *
By signing this form I agree to: 1. We have read the Bellows Falls Middle School Student Intramurals Handbook 2. Giving my child permission to participate in athletics at Bellows Falls Middle School and have provided all required information/documentation. 3. We have received a copy of the Concussion Fact Sheets *
Parent Signature (Please write your name below) *
Student Signature (Please write your name below) *
A copy of your responses will be emailed to the address you provided.
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